A MESSAGE FROM FETAL MONITORING CREDENTIALING (FMC) INTRODUCTION Why did we start such a program? Perhaps the most problematic issue in modern obstetrics is the interpretation and management of fetal heart rate patterns during labor. There continues to be a lack of consensus in electronic fetal heart rate monitoring interpretation by experts. Recent research points to the intrapartum period as the contributing time for neonatal encephalopathy. Errors and variations in interpretation of electronic fetal monitoring (EFM) strips may result in poor management decisions that contribute to subsequent neonatal encephalopathy. Electronic fetal heart rate monitoring abnormalities are increasingly used as justification for emergency delivery by clinicians resulting in a marked and continuous rise in cesarean section rate. Finally an unfortunate explosion in litigation involving the fetal heart rate patterns has resulted as well, leading to a very challenging atmosphere in any modern Labor and Delivery unit. It is believed that at least a portion of the inconsistent evidence supporting the efficacy of EFM results from poor interpretation and communication among members of the healthcare team. Further, there is a lack of standardized protocols for the management of challenging patterns. It is further believed that with the common clinical language and understanding of specific terms that better communication will result and that in turn will lead to the universally held goal of improvement in patient safety. Why should you do credentialing in EFM? Currently, there are numerous institutions and entities requiring credentialing in electronic fetal monitoring for all health care providers working in Labor and Delivery units. Although this is generally limited to specific institutions at this time, there is no doubt that this expectation of credentialing will expand nationally. In addition to hospital systems requiring such reviews (i.e., universities on the East coast such as, Yale, Columbia, Duke and metropolitan hospital system in Cleveland, Ohio), there are many insurance companies either requiring or encouraging such a process in EFM. This is associated with reductions in premiums or the decision to even write malpractice premiums in practitioners of obstetrics. Further, Leap Frog, Joint Commission and CMS have every intention to expect institutions to be able to provide evidence of performance improvement and credentialing in various aspects of healthcare. Finally, there is no doubt that even with or without these various requirements, institutions will want to be able to demonstrate the knowledge and performance measures that are necessary and tied with their own reimbursements. Consequently, we believe that this credentialing examination is both timely and valuable. Why should you use such an examination? As academicians and clinicians, we strongly believe there is real value with EFM. We have also realized that there continues to be an inability to maximize this technology with respect to assuring safe birth of the unborn and overall patient safety. While there is no question to the value of EFM in establishing that a fetus is well oxygenated and not acidotic when the generated tracing is normal and that there is an increased risk of acute or pre-‐existing injury and/or long-‐term neurological compromise when EFM is distinctly abnormal, the fact remains that there is a remarkable lack of consistency in how an EFM tracing is interpreted and managed. Indeed, if we were to go to your labor and delivery unit right now and randomly choose an EFM tracing from a laboring patient in your institution there is a very high likelihood that its interpretation will vary among nurses and physicians asked for their opinions. How this information is interpreted, communicated, distilled and acted upon is unpredictable and all too often incorrect. We believe this credentialing test is a unique tool to identify specific areas of importance in EFM. Further, based upon established specific learning objectives, we can earmark those areas wherein a clinician may have weaknesses and require feedback and additional remediation. This test combines knowledge questions and clinical scenario questions (called Script Concordance Testing). These types of questions lend themselves to electronic fetal monitoring assessment and credentialing. Knowledge questions (KT) have a specific correct answer or answers and they are generally based upon specific definitions nomenclature or physiologic facts. They can be used to measure any number of specific teaching objectives. Script concordance questions (SCT) are a recently used innovative approach to clinical reasoning assessment and lend themselves directly to evaluation of clinical decision-‐making. SCT testing includes a stem question that generally establishes a specific clinical scenario and initial management plan. When facing clinical problems, physicians, nurse midwives and obstetrical nurses mobilize pre-‐ existing sets of knowledge (“scripts”) and respond when additional specific information is provided as the case evolves. SCT questions have 5 possible answers and the answer key utilizes a 5 point Likert Scale allowing for more than one answer to be acceptable with full or partial credit given at times for 3 of the answers. The test we have for credentialing includes some 70 questions that were generated by a group of physicians and nurse question writers. Based upon the concordance of answers provided by each group of experts, the final 70 questions were selected and the test was assessed for its statistical validity. Both the KT and SCT questions achieved statistical significance for these tests (one for physicians, one for nurses). Consequently we believe we have a statistically valid method of testing that implements a very modern technique which is highly applicable to the area of EFM credentialing. Who is PQF? The Perinatal Quality Foundation grew out of Society of Maternal Fetal Medicine and is now an independent affiliate of SMFM. The Perinatal Quality Foundation Board and volunteers are composed of some of the most respected clinicians in Maternal Fetal Medicine. As an example of the level of leadership, PQF is the group that instituted the Nuchal Translucency Quality Review (NTQR) perinatal quality program for the industry. Consistency in Nuchal Translucency measurements improves the identification of newborns at higher risk for Down Syndrome and certain other chromosomal abnormalities. Currently over 7,400 clinicians are monitored as part of this initiative that has analyzed over 3 million measurement data sets. The mission of the Perinatal Quality Foundation is to improve the quality of Obstetrical services. Hospital Labor and Delivery units are a primary focus for improvement in fetal safety. The foundation is committed to disseminating safe and excellent obstetrical practice protocols, to providing clinician and provider education, monitoring measures, and consensus discussions on emerging obstetrical technologies and to supporting research. PQF is independent from any provider of classes, courses, or programs. The foundation is a not for profit organization. PQF experts are continually updating and reviewing test items and pass/fail standards, reviewing examination statistics and undertaking content validation studies. The Privacy Statement can be viewed on line if more information is needed.
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